18,19, 22 & 24 June 2015
During a routine inspection
We undertook this unannounced comprehensive inspection on the 18, 19, 22 and 24 June 2015. At the last inspection on 12 and 13 September 2013 we found the registered provider was compliant in the areas we assessed.
Hadleigh House Residential Home provided personal care to a maximum of 35 older people who had a range of physical health care needs, some of whom were living with dementia. On the first day of the inspection visit there were 25 people using the service. Hadleigh House Residential Home was situated in a residential area not far from the centre of Immingham.
There was a registered manager for Hadleigh House Residential Home, however they gave notice and resigned on the first day of the inspection. A registered manager is a person who has registered with the Care Quality Commission [CQC] to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found the registered provider was in serious breach of ten regulations of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. These were in relation to person centered care, dignity and respect, safe care, safeguarding people from abuse, safety and suitability of the premises, cleanliness and infection control, staffing levels, supporting workers, obtaining consent and working within the requirements of the Mental Capacity Act 2005, assessing and monitoring the quality of service provision, fitness of the director and fitness of the registered manager. We also found a breach of Regulation 18 of the Care Quality Commission [Registration] Regulations 2009 for non-notification of incidents. The majority of these breaches were assessed by CQC as extreme, as the seriousness of the concerns placed a significant risk on the lives, health and well-being of the people living in the home.
There had been a failure to protect people from harm and abuse and to recognise and report when people had been put at risk or had been subject to harmful situations. This meant the local safeguarding policies and procedures had not been followed in these instances and also meant there was a delay in the safeguarding team having the opportunity to comment on the incidents, provide advice or take any action.
The staff did not have the knowledge and skills to support people or follow legal processes to make decisions in their best interests. People living at the home were subject to restrictive
practice which had not been identified or managed in line with the Mental Capacity Act [MCA] 2005 and The Deprivation of Liberty Safeguards [DoLS].
Records showed staff had been recruited safely but there were not enough staff available to meet the needs or maintain the safety of the people living at the home. Due to the serious concerns about the shortages of senior care staff identified during the inspection, the assistant director of North East Lincolnshire Clinical Commissioning Group arranged for additional staff from an external source to work at the service to oversee and ensure people’s safety and welfare was maintained.
Routines were busy, disorganised and care support rushed. Although staff were kind and willing they had a task based approach to care and did not always promote and protect people’s safety and dignity.
The environment at Hadleigh House was poorly maintained and unsafe. Fire safety systems were not properly maintained or followed. There had been limited adaptations to support people living with dementia. The premises were also very unclean and placed people at risk from infection.
There was a lack of regard for people’s social and recreational needs and a lack of opportunity to engage in activities, entertainment or visits into the community. People were sitting in the lounges or their bedroom with no meaningful activity or positive interaction taking place.
We found people’s preferences, choices, likes and dislikes were not explored with them. This meant the service could not deliver individualised care and support that was in line with what people wanted and needed.
Care plans were poorly written and did not describe people’s needs properly. People’s changing healthcare needs were not known and understood. People were at risk of harm because the service failed to respond promptly and appropriately to new care needs. People did not have risk assessments in place for specific concerns. Incidents and accidents had not been analysed to help find ways to reduce them.
Whilst people told us they enjoyed the meals served to them at Hadleigh House the home did not have a robust way of monitoring people’s nutritional and fluid intake. This meant they could not evidence that some people were receiving sufficient food and drink to maintain their health and wellbeing. People had lost weight but this had not been recognised and followed up.
Overall, we found safe systems in place for obtaining, storing, administering and recording medicines. However, when medicine errors had taken place steps were not always put in place to minimise the risk of these errors occurring again in the future. Staff who had made the errors were not given additional training and assessed as being competent to administer medicines following the errors.
The service was poorly led, with a lack of management support in the home. There were no effective systems or processes in the home to ensure that the service provided was safe, effective, caring, responsive or well led. The interim management team and registered provider were unable to demonstrate the skills, knowledge or ability to make the urgent changes that were required to make the service safe during the time period that the inspection took place.
CQC used it’s urgent powers to apply to the Magistrates Court on 29 June 2015 and received a court order to cancel the registered provider’s registration to carry out the regulated activity of accommodation for persons who require nursing or personal care at Hadleigh House Residential Home.